The differential diagnosis of shock following percutaneous coronary intervention (PCI) is vast. Access site complications and bleeding can cause hypovolemic shock. Peri-procedural myocardial infarction, abrupt closure, stent thrombosis, coronary dissection and coronary perforation have a stormy presentation. Vasovagal shock is manifested by bradycardia and hypotension and quickly responds to atropine. Anaphylactic shock secondary to contrast administration can be stormy but usually responds to steroids or adrenaline. Septicemia due to unsterile techniques can cause a less dramatic shock. Acute adrenal insufficiency causing shock following PCI has not been described to the best of our knowledge. We report the case of a 54-year-old woman who underwent successful multivessel PCI. She had refractory unexplained shock following the PCI with no much response from inotropic or intra-aortic balloon pump. After ruling out all possible causes of shock and clinical suspicion of adrenal insufficiency, she was treated with steroids resulting in dramatic improvement in her hemodynamics. © BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.A 70-year-old man presented with acute respiratory failure, alveolar infiltrates and haemoptysis requiring supplemental oxygen. Flexible bronchoscopy with bronchoalveolar lavage identifies diffuse alveolar haemorrhage. Clinical and serological evaluations do not identify a precise aetiology and histopathology establishes the diagnosis of isolated pauci-immune pulmonary capillaritis. The patient received induction therapy with high dose methylprednisolone at 1000?mg/day for 5?days and weekly rituximab at 375?mg/m2 scheduled over 4?weeks. Although the patient demonstrated clinical improvement after the first week, he experienced a rapid relapse requiring mechanical ventilation. His induction rituximab regimen was continued and plasma exchange was initiated. Despite these therapies, the patient's condition deteriorated and passed away. Our case adds insight to the management of this rare entity and describes the use of plasma exchange as salvage therapy. © BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.Paraganglioma of the bladder is a rare tumour accounting for less than 0.06% of all urinary bladder tumours and has varied presentations. It may present with clinical symptoms of phaeochromocytoma, may be non-functioning and asymptomatic or may present with haematuria. Hence, paragangliomas are occasionally misdiagnosed, and this results in unanticipated intraoperative hypertensive crisis. We present the case of a 44-year-old woman with urinary bladder paraganglioma who presented with young onset hypertension, recurrent micturition syncope with prior history of coronary artery disease and stroke. She was stabilised preoperatively with alpha blocking agents and subsequently underwent successful transurethral resection of the same. © BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.A 71-year-old man was admitted with confusion having been discovered on the floor of his unkempt home. Social services would later confirm that the home was infested by rats. An infection of unclear origin was suspected, and he was immediately started on broad spectrum antibiotics. He subsequently developed a swollen left knee. Two knee aspirates showed a raised white cell count but no microbiological or cytological diagnosis. Finally, samples sent for 16S rDNA PCR identified Streptobacillus monilliformis Fastidious organisms and early treatment with antibiotics can limit microbiological diagnosis through standard laboratory analysis. Newer techniques such as sequence-based testing can overcome these limitations; however, they are not widely available and require the clinician to have a high index of suspicion. Crucially, the patient continued to be treated for his clinical sepsis despite initial laboratory results being negative and conflicting specialist opinions. © BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.Intravenous leiomyomatosis is extremely rare. This case describes a 42-year-old woman who presented with abdominal distension, cyclical bloating and urinary retention. Preoperative imaging showed a multilobulated uterine mass. Following multidisciplinary team discussion, a complete staging surgery consisting of midline laparotomy, total hysterectomy and bilateral salpingo-oophrectomy was performed. Intraoperatively, a large multilobulated uterine mass was noted with engorgement of the infundibulopelvic ligaments due to intravascular extension of tumour. On removal of the uterus, the patient desaturated and became hypotensive. Intraoperative transoesophageal echocardiography revealed mass extending from the inferior vena cava (IVC) into the right atrium (RA). The cardiothoracic surgical team retrieved a worm-like mass extending from the IVC into the RA. Histopathological examination diagnosed a large uterine leiomyoma with intravenous leiomyomatosis. https://www.selleckchem.com/products/sr-0813.html The mass from the RA was a bland spindle cell tumour which matched the uterine mass histopathologically. Intravenous leiomyomatosis is a rare variant of uterine leiomyoma. Although intracardiac extension has been described, this is the first case of intraoperative embolisation of pelvic tumour to the RA at hysterectomy. © BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.An 18-year-old male adolescent presented with prolonged high spiking temperature, photosensitive rash, oral ulcers and reduced hearing bilaterally of recent onset. Examination revealed malar rash, vasculitis rash over bilateral palms and soles, oral and buccal ulcers, palpable posterior auricular and inguinal lymph nodes, and reduced hearing bilaterally. His further investigations noted pancytopaenia, elevated transaminases, hyperferritinaemia, low C3 and C4 levels, positive antinuclear antibody, double-stranded DNA and direct Coombs test, while bone marrow aspiration revealed active phagocytic activity suggestive of hemophagocytic syndrome. We made a diagnosis of systemic lupus erythematosus with macrophage activation syndrome. We treated him with pulse intravenous methylprednisolone and his condition improved drastically. Temperature resolved on the next day after intravenous methylprednisolone; bilateral sensorineural hearing loss improved to near-normal hearing after treatment. He remained well during follow-up with a tapering dose of prednisolone.